Application for Dispensing Organization Authorization - Illinois

Application for Dispensing Organization Authorization ?

Medical Cannabis Division

The Application Form, Fees, Addenda A, B, C, D, E, F, and G, Schedules 1, 2, 3, 4, and 5 and the information required by each Schedule must be submitted by all applicants. The information in Schedule 6, Bonus Section, is optional. Applicants are encouraged to draft the narrative portions of the application clearly and concisely.

Diagrams, Plot Plans and Photographs are required with the application. Application diagrams, plot plans or photographs may be applicable to more than one Schedule. In this situation, please submit one copy and reference the Schedule number on any subsequent Schedules. The Division requires permission to reproduce all drawings.

In order to aid the Division in reviewing and scoring applications anonymously, please DO NOT use your company name or distinguishing characteristics in Schedules 1-5. Department staff that will be involved in the reviewing and scoring of applications will NOT be involved in the acceptance and recording of applications.

Schedules:

Schedule 1 ? Suitability of Proposed Dispensary Schedule 2 ? Business and Operations Plan Schedule 3 ? Security Plan Schedule 4 ? Recordkeeping and Inventory Plan Schedule 5 ? Financial Disclosures Schedule 6 ? Bonus Section

REQUIRED REQUIRED REQUIRED REQUIRED REQUIRED OPTIONAL

150 Points 200 Points 200 Points 200 Points 150 Points 100 Points

Mandatory Addenda:

Addendum A. Attestations: Each principal officer must sign and date the Medical Cannabis Principal Officer Attestation Form.

Addendum B. Certifications: Each principal officer must sign and date his or her own Medical Cannabis Principal Officer Certification Form.

Addendum C. Property Ownership Form. Addendum D. Zoning Form. Addendum E. Criminal History Form Addendum F. A fingerprint receipt from a licensed livescan vendor for each Principal Officer

listed in the application, including all information from Section 230 of the Administrative Rules. Addendum G. Photocopy of Application Fee.

NOTE: It is extremely important that the information submitted with the application and the schedules, clearly shows compliance with the rules of the Department, found at 68 Ill. Adm. Code Part 1290. It is strongly recommended that the applicant read and become familiar with the rules, a copy of which is available online at mcpp..

Pursuant to the Administrative Rules, a non-refundable application fee of $5,000 shall be submitted with each application.

Please contact the Department of Financial and Professional Regulation at the email address below if you have questions. FPR.MedicalCannabis@

Nothing in this application is intended to confer a property or other right, duty, privilege or interest entitling an applicant to an administrative hearing upon denial of an application.

IL486-2109 8/14

IMPORTANT NOTICE: Completion of this form is necessary for consideration for licensure. ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION

APPLICATION FOR A MEDICAL CANNABIS DISPENSING ORGANIZATION

FOR OFFICIAL USE ONLY

PART I: Application Category Information

1. BUSINESS NAME:

2. BUSINESS MAILING ADDRESS:

3. BUSINESS TELEPHONE NUMBER:

4. IDENTIFY THE TYPE OF BUSINESS STRUCTURE (check one):

Sole Proprietorship

Partnership

Limited Partnership

C Corporation

S Corporation

Publicly Traded Corporation

5. DATE OF FORMATION / INCORPORATION OF APPLICANT BUSINESS ENTITY:

LLC Other

6. STATE OF INCORPORATION, OR FORMATION OF BUSINESS ENTITY:

7. FEIN:

8. REGISTERED WITH THE ILLINOIS SECRETARY OF STATE? PROVIDE CERTIFICATION OF GOOD STANDING WITH ILLINOIS SECRETARY OF STATE.

9. D/B/A/ NAME:

10. REGISTERED AGENT NAME:

11. REGISTERED AGENT ADDRESS:

12. PROPOSED BUSINESS NAME, IF ANY:

13. GIS COORDINATES OF PROPOSED LOCATION:

14. PROPOSED DISPENSARY NAME: 15. DISPENSARY'S PROPOSED PHYSICAL ADDRESS:

16. DISTRICT NUMBER:

PART II: Ownership Structure (List each Principal Officer and for each include):

Please attach a separate sheet of paper for each Principal Officer. Review Administrative Rules Section 1290.30 for the people who qualify as a principal officer of a dispensing organization.

18. NAME FIRST

MIDDLE LAST (MAIDEN NAME IF APPLICABLE):

19. DATE OF BIRTH:

20. ALIAS OR ANY NAMES YOU HAVE BEEN KNOWN BY:

21. SEX (OPTIONAL) 22. RACE (OPTIONAL) 23. US CITIZEN?:

24. ILLINOIS RESIDENT?: 25. SOCIAL SECURITY NO.:

26. RESIDENCE ADDRESS (CANNOT BE A PO BOX): 27. BUSINESS ADDRESS (CANNOT BE A PO BOX):

28. TELEPHONE NUMBER (WORK AND CELLULAR):

29. EMAIL ADDRESS:

30. TITLE RELEVANT TO THE PROPOSED DISPENSARY BUSINESS:

31. PERCENT OWNERSHIP:

32. TYPE OF OWNERSHIP:

IL486-2109

33. a. b.

List any persons and/or entities with an ownership interest in the dispensing organization that are not listed as Principal Officers or dispensary backers. Attach document. If an entity, list all persons with an ownership interest in the entity, their percentage ownership interest in the entity, and their effective ownership interest in the registration. If a person, list their percentage ownership interest in the entity, and their effective ownership interest in the registration.

Person or Entity

Ownership / Interest

a.

b. c.

d.

e.

34.

Are there any other persons and/or entities, who will receive directly or indirectly, any compensation or future compensation based

upon a percentage or share of the gross proceeds or income of the dispensing organization?

a. If yes, identify each person and list their interest in the business.

Person or Entity

Ownership / Interest in Entity

Ownership / Interest in Registration

35.

Provide both the business name, individual name and contact information for each facility backer, business partner, investor, joint

venture and/or registered agent and anyone with more than one percent ownership interest, future ownership interest or debt to

equity interest.

Name

Type of Interest or Ownership

a. b. c. d. e. IL486-2109

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Dispensary Organization Primary Contact (must be a principal officer of the Dispensing Organization)

36. NAME:

37. TITLE:

38. ADDRESS:

39. PHONE NUMBER:

40. EMAIL:

Dispensary Organization Alternate Contact (must be a principal officer of the Dispensing Organization)

41. NAME:

42. TITLE:

43. ADDRESS:

44. PHONE NUMBER:

45. EMAIL:

46. Other than this application, name any other Dispensing Organization Districts this applicant is applying for during this application period in September, 2014. Note: An organization applicant may submit applications in no more than five districts. Each individual may only apply, or be a part of an organization applying, in no more than five districts.

Provide a list of the names of all principal officers, and beside each name, the district or districts where each principal officer has submitted a dispensary authorization application.

a.

b. c.

d.

e.

47. Is this applicant also applying for a cultivation center permit with the Illinois Department of Agriculture?

Yes

No

If yes, provide the districts.

Provide a list of the names of all principal officers and beside each name, the district or districts where each principal officer has submitted an application with the Illinois Department of Agriculture for a cultivation center.

a. b. c. d. e.

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Business Information

Identify the type of business entity.

a. If the entity applying is a sole proprietorship, a copy of creation documents.

b. If a partnership, a copy of any partnership or joint venture documents, and if there is no written agreement, a statement signed by all Principal Officers affirming there is no agreement.

c. If a limited liability company, a copy of the Articles of Organization, operating agreement, and certificate of good standing issued by the Secretary of State or obtained from the Secretary of State's website dated within seven days prior to the date application is filed with the Division. Limited liability company applicants must include a listing of all affiliated persons or business entities holding an ownership interest in the company.

d. If a corporation, the name of the registered agent, a copy of the Articles of Incorporation, Corporate Resolutions if any, and, a certificate of good standing issued by the Secretary of State or obtained from the Secretary of State's website within seven days of the application date. If using an assumed name, submit a copy of the assumed name certificate or registration issued by the Secretary of State. Corporate applicants must include a listing of all persons or businesses holding an ownership interest in the corporation.

e. If an unincorporated association, organization or not-for-profit organization, documents or agreements relevant to its creation, ownership, profit sharing and liability. If there are no documents as detailed in section 1290.50(a)(5)(E) of the Administrative Rules, a statement signed by all principal officers affirming so.

48. Name of dispensary organization's proposed agent in charge.

49. Name of person, firm or business that has assisted the applicant draft, assemble or submit this application, if applicable.

50. Name of the institution holding the minimum amount in liquid assets or funds required by the Administrative Rules.

51. Provide a copy of the dispensing organization's proposed operating by-laws including provisions for amending them.

a. The by-laws must include procedures for the oversight of the dispensing organization and procedures to ensure accurate record keeping, patient confidentiality and security measures that are in accordance with the Division's rules.

b. The by-laws must include a description of the enclosed and locked facility where medical cannabis will be stored. 52. Provide documents of the dispensing organization's ownership structure that establish the legal and business structure of the

applicant, operations, management and control including organization chart that provides position descriptions and the names of each person holding each position and percentage ownership of each person or entity. Attach a copy 53 Provide any additional documents that establish the legal and business structure of the applicant, operations, management and/or control. If none, please state so. Attach document.

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SCHEDULE 1. SUITABILITY OF THE PROPOSED DISPENSARY

SUITABILITY FOR PUBLIC ACCESS (Limit to 3 pages)

1.

Provide a narrative explaining why the proposed location is suitable for public access, the size and layout

promote safe dispensing of medical cannabis, product handling, and storage. Include detailed plans for

handicapped accessible parking and ADA accessibility.

2.

Provide a narrative statement describing specific elements in your plan that will favor the immediate community

and why your operations will negate any detrimental impact.

PLOT PLANS and PHOTOGRAPHS: Plot map and drawings must be adequate in size to illustrate your plans. For this section, applicants must:

1.

Provide a location area map of the area surrounding the proposed dispensary, extending a minimum of

1,000 feet from the proposed dispensary property line in all directions. Clearly identify the existing adjacent

businesses or residences.

2.

Clearly demonstrate that the property line of the proposed dispensary is not located within 1,000 feet of the

property line of a pre-existing public or private preschool or elementary or secondary school or day care center,

day care home, group day care home or part day child care facility identified in Section 130 of the Act.

3.

Provide a drawing depicting the property that extends at least to the property line perimeter, defining exterior

landscape and interior layout, including storage and delivery areas.

4.

Provide color photographs of the proposed dispensary and immediately adjacent area.

ZONING:

1.

Copy of the current local zoning ordinance as it relates to dispensaries.

2.

Narrative of how the proposed dispensary location complies with the local zoning ordinance or rules.

3.

Documentation, if any, of the approval, conditional approval or the status of a request for approval, from the

local zoning office.

4.

Copy of DFPR Zoning Form with signature from the local zoning office providing confirmation that the proposed

dispensary location is in compliance with local zoning provisions and those identified in Section 130 of the

Act. If the applicant cannot secure a signature for the DFPR Zoning Form, provide a statement describing the

reason(s).

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SCHEDULE 2. BUSINESS AND OPERATIONS PLAN

KNOWLEDGE AND EXPERIENCE: 1. Resume for each Principal Officer.

a. Identify the name of each Principal Officer's present employer, position held and dates of employment. b. Identify academic degrees, certifications or relevant experience with a state sanctioned medical cannabis

business or related industry. Demonstrate knowledge of cannabis product strains or varieties, and describe the types and quantities of products planned to be offered, including paraphernalia or edibles. c. Applicant's principal officers must demonstrate experience and qualifications in business management or experience in the medical cannabis industry. 2. Name and resume for each agent in charge.

STAFFING PLAN: (Limit to 3 pages) 1. Provide job descriptions, hiring procedures and staff reporting procedures on inventory loss or irregularities. 2. Include a description of the training and education that will be provided to dispensary agents. 3. Include best practices for day-to-day dispensary staffing. 4. Provide estimated staffing levels during hours of operations.

BUSINESS MANAGEMENT PRACTICES: (Limit to 5 pages) 1. Describe how the dispensing organization will be managed on a short and long-term basis, including the immediate

and long-term financial health and resources for the design, development and operation of the dispensary. 2. Include best practices for day-to-day dispensary management. 3. Describe the patient verification system, purchases and denials of sale, and confidentiality.

OPERATING PLAN: (Limit to 5 pages) 1. Include, at a minimum, a timetable that provides estimated build out and start up time from authorization through

year one of registration. Include the basis for those estimates. 2. The process of storing cannabis, and dispensing it from a restricted access area to a limited access area. 3. Description or copy of proposed marketing or advertising plan or materials, if any. 4. Description of proposed text or graphic materials on building exterior. 5. Proposed hours of operation.

SERVICES PROVIDED: (Limit to 3 pages) 1. A general description of products, varieties and services related to medical cannabis (if any) intended to be offered

and reasoning for those choices.

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SCHEDULE 3. SECURITY PLAN

FACILITY SECURITY: Submit or include on a separate drawing the following: 1. Diagram of dispensary drawn to scale, including general specifications of the building exterior and interior

layout, identifying all points of entry and exit and locations of security or surveillance devices. Note: Diagrams must be adequate in size and resolution to illustrate the type of security or surveillance devices.

2. Whether security personnel will be on-site during operational or non-operational hours.

SECURITY SURVEILLANCE SYSTEM: (Limit to 6 pages, excluding supporting documents, i.e. designs or drawings)

1. Provide a narrative of the type of surveillance system that will be installed, controls used to monitor and secure the premises, agents, patients, caregivers, currency and measures that will prevent the diversion, theft or loss of cannabis and currency.

2. Identify whether applicant will retain an outside vendor to design and implement a security system or provide a security guard.

3. Provide the storage capabilities for the retention of historic recordings on-site and off-site. 4. Name the process and system used to provide real time video feed to the Illinois State Police and the Division.

PRODUCT SECURITY: The security plan should demonstrate the capability for the prevention of the theft or diversion of medical cannabis. (Limit to 6 pages, excluding supporting documents)

1. Submit a plan to control inventory from receipt through sale. 2. Identify measures to restrict access to the limited access areas to qualifying patients, designated caregivers,

registered agents, service professionals and security personnel. 3. Identify measures to prevent unauthorized entry and theft from restricted access areas. 4. Procedures for documentation of both cannabis loss and destruction.

SHIPPING/TRANSPORTATION SECURITY MEASURES: Submit the operational procedures for receipt of product. This shall include the following. (Limit to 3 pages) 1. A description of the receipt of delivery process, including receipt and log of manifests. 2. Security protocols used to avoid diversion, theft or loss at the acceptance point. 3. How the applicant will confirm receipt of all products from the cultivation center.

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